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On a message board I frequent, a mother recently asked how many of us obey the “don’t feed formula left out over 2 hours” rule. While most people responded that they did abide by this recommendation, a conversation ensued about why we we’d all been told to do this. The answers varied, from vague concepts about bacteria spreading in room temperature bottles, to warnings that the nutrient content of the formula would decrease as time went on.

This all got me wondering: what is the reason we’re told to be so careful about not letting our babies consume “old” formula? For a snacker like Fearlette is – especially one on $30-a-can Alimentum – this rule is a real drag. My sick little theory was that this rule is all b.s., a combined ploy of the formula manufacturers and breastfeeding pushers who want to make it more costly and aggravating to formula feed. So I started researching… and I found plenty of studies on how formula feeding moms don’t follow safe practices, and articles about how unsafe formula handling can kill babies… but no concrete facts, statistics, or studies about just how room-temperature formula becomes an instrument of morbidity.

Go figure, right?

Anyway, let me share with you the information I could find. An Infant Formula Council document warns that the longer formula is left at room temperature, the more likely it is to become contaminated with a bacteria called Enterobacter sakazakii, which can indeed be lethal for premature infants or those with compromised immune systems for other reasons:

A microorganism of particular concern, and which can survive in powdered infant formula, is Enterobacter sakazakii (E. sakazakii). E. sakazakii is an opportunistic pathogen that poses little risk to healthy, term infants. However, in certain highly vulnerable infants this microorganism can cause serious infection that can present severe and life­threatening conditions, including meningitis. This most commonly occurs in low birth weight and immuno­compromised infants, in whom isolated outbreaks of E. sakazakii infections have been reported in a few hospital settings. Some of these cases have been linked to the improper preparation and storage of reconstituted powdered infant formula. For example, blenders used to reconstitute formula have been shown to harbor bacteria. Because reconstituted powdered infant formula is rich in nutrients and is not sterile, it provides a good medium for microbial growth under certain conditions. For example, prolonged periods of storage or administration of prepared powdered infant formula at room temperature will increase the bacterial load. Thus, proper handling and use of powdered infant formula in the health care setting is an important patient safety issue.

In the United States, infant formulas are available in 3 types: ready-to-feed, liquid concentrate, and powdered. Liquid concentrates and powders require appropriate dilution with clean water. Adding too much water may lead to inadequate intake of calories and nutrients, whereas adding too little water may lead to dehydration, diarrhea, and excessive intake of calories. The safety of liquid concentrate and powdered formulas can be compromised if they are diluted with water of poor quality.1 Unlike ready-to-feed and liquid concentrates, powdered formulas are not sterile when purchased and could contain bacteria. To reduce the risk of infant illness caused by bacteria in powdered formula,3 the World Health Organization urges caregivers to use water no less than 158°F when reconstituting powdered formula.4

I checked the references of both these articles – which were coming from two different organizations with dramatically different biases (the AAP one was written, in part, by an IBCLC) – and it was insanely frustrating, They used other articles as backup for these theories that also offered no stark data. I couldn’t find any documentation of cases where children got sick from formula left out of the fridge too long, or suffered long-term health effects because their parents let them drink a bottle they’d been snacking on for 2 hours and 15 minutes.

In terms of preventing contamination Enterobacter sakazakii (ES), a rather stubborn bacteria which does indeed confer risks to infant formula, I did find a long chain of good studies which examined how this bug can survive even under refrigeration, and can cling to surfaces which makes it a real threat in NICU units. Apparently, the longer formula is left out, the more likely it is to become contaminated. But again… no concrete evidence.

Here is what I would like to know (and gold stars for anyone who can find a study which answers these questions):

1. Many of the studies on ES recommend using breast milk or ready-t0-feed formula, since ES has been found in cans of powdered formula…but then they also discuss other ways the bacteria can spread, like through feeding tubes, etc. Couldn’t this bacteria theoretically infect a baby in the NICU fed through one of these tubes with human milk or RTF formula? If so, shouldn’t this be added to the warning? According to this study, ES can thrive in breastmilk; also, although we are innundated with the message that “formula is not sterile” and therefore unsafe…. neither is expressed breastmilk, for the exact same reasons. I don’t see much information on dangerous bacteria being passed to the millions of women who pump their breastmilk daily, and I think it’s worth mentioning.

2. Have there been any documented cases of an infant becoming sick after consuming formula left out more than 2 hours? Why is the 2 hours the limit? I’m looking specifically for a study which examined harmful bacteria growth on a sample of formula over time…

Now, none of this is to say that formula-related dangers don’t exist. I personally know a few parents who’ve experienced health crises due to improper formula usage, which is why I think formula education is incredibly important. It makes complete sense that we should wash our hands prior to making a bottle, or use safe water (there are PLENTY of documented cases in developing nations of babies dying from formula made with contaminated water). But the no-bottles-after-2-hours rule, in areas with clean water or in cases where purified water is being used, just seems to have a startling absence of evidence to back it up.

It seems that this recommendation is based on pure hypotheticals – bacteria could feasibly grow in formula, and two hours seems like a decent cut-off point. But where is the evidence? If we’re seriously concerned about our babies’ safety, shouldn’t we be demanding some real statistics on this potential threat?

Interestingly, while researching this post, I came across a study done by the company which makes Dr. Brown’s bottles. The study looked at how the type of bottle can effect the nutrient decomposition of both breastmilk and formula:

The study measured the level of loss of vitamins A, C and E during baby bottle feedings. The results suggest that the amount of air within a baby bottle, the bottle’s design, and the impact on vitamin levels warrant closer examination….The bottle study was designed to investigate changes in nutrient levels that might occur during a typical bottle feeding time of 20 minutes, using both expressed human milk and infant formula, in both vented bottles and unvented bottles…

As milk is removed from the bottle by the infant, the milk is replaced by ambient air. Nutrient loss is likely caused by the oxidation of nutrients that takes place as air is introduced into the liquid. The amount of air moving through the milk and into the bottle depends on the bottle type, bottle shape, and bottle size.

The lead researcher on this study also mentioned that storage of both human and formula milk could effect the nutrient levels. She offered the following tips for bottle-feeding moms:

• Select bottles that minimize air traveling through the bottle.

• Look for little to no bubbles forming in the milk as the baby feeds.

• Use breastmilk that is as fresh as possible.

• Use small bottles that minimize the amount of air at the top of the milk.

• When using infant formula, make it fresh for every feeding.

• Feed babies with small, frequent feedings.

Although this study was funded by the makers of the same bottle which fared the best in the study (Dr. Brown’s), I still think it’s a superb example of the type of research we should be focusing on. It tells us a specific effect of a specific behavior, and offers suggestions to counteract the negative results of the study. Good, useful, empowering information.

I’m certainly not in the business of giving recommendations, and as I’ve said a million times before, I am not a doctor, nor do I play one on tv. But here’s my personal take on it: I’d be pretty careful about the 2-hour rule if your baby is under 6 months old or immuno-compromised in any way. But after that… I don’t know. The fact is, once your kid is on solids, they are going to be at risk for foodborne illness from all sorts of products, not just infant formula. I haven’t found any research that makes me believe Fearlette is at risk because I let her snack on the same bottle for 3 hours rather than 2.

For the past two years, I’ve spent a lot of time reading about breastfeeding. A lot of time. And while I (obviously) find the subject infinitely interesting, I’ve started missing my guiltiest of guilty pleasures: reading “chick-lit”.

Luckily for me, a book has come along that merges my professional interests with my penchant for witty, engaging stories with female protagonists. A book – wait for it – about the breastfeeding “wars”. One that pokes fun, equally, at La Leche League regulars and bloggers like me.

Milkshake, a new book by Boston Globe columnist Joanna Weiss, is a satirical take on the extreme sport of motherhood. We meet its heroine, Lauren, when she’s a day or two post-partum, still at the hospital, and taking the requisite “baby care” class (where the prominent message is that formula is comparable to crack).

….Lauren looked down at her own breasts…and thought about what breastfeeding was going to entail. She was dreading the moments when she had to provide love in a liquid form, but her fear was no match for the power of guilt. She had read the pamphlets listing the vast health benefits of breastmilk. She had watched her friend Mia shake her head and murmur, “That poor child,” when she saw mothers bottle-feeding on the banks of Jamaica Pond. She had seen the government-sponsored pro-breastfeeding ads: a dirty factory labeled “INFANT FORMULA INC.”; a baby crying in a metal bassinet; the tagline, “Breastmilk. For mommies who care.”

Lauren is committed to breastfeeding, and luckily doesn’t face any major roadblocks. But like any new mom, it takes time for her and her daughter Rory to get a rhythm going, and public breastfeeding proves challenging. When Lauren accidentally flashes a group of high school boys while attempting to nurse in the middle of the art museum, she finds herself the unwitting symbol of the breastfeeding-in-public debate; a pawn of a power-hungry politician, and the poster child for BOOB (Boston Organization for the Oversight of Breastfeeding).

On the other side of the ensuing media circus is Claire Langoon, who runs the blog “www.hurtslikeabitch.com.” I’m not sure if Weiss was at all aware of this blog when she wrote the book, but I definitely related to Claire as a far hipper version of myself, with a different slant to her message – she sounds more like a younger, American version of Elizabeth Badinter – but the same bottom-line intent: to bring moderation to the discussion. Claire argues that switching from breast to formula allowed her to feel truly free; that the pressure to breastfeed is just another way to bring women down.

Lauren is struggling with the transition to motherhood, and isn’t quite sure where she fits in. Although she’s being paraded around town as a breastfeeding role model, she finds herself questioning the more extremist views of those surrounding her. When her best frenemy Mia, a Type-A sanctimommy, aggressively confronts a woman buying formula in the grocery store, Lauren balks. She asks Mia how she could do such a thing:

“All that is necessary for evil to prevail is for good people to do nothing,” Mia replied.

“That woman isn’t evil,” Lauren said. “Maybe she has a problem with her breasts, or—I don’t know. What does it matter to you?”

“It matters because it’s a slippery slope,” Mia said. “You really need to talk to Sheila about this. One of the things we have to do is stigmatize formula, so that it becomes socially unacceptable. So people are ashamed. Smoking used to look cool, you know, but now it just makes you look like a skank.”

“Smoking actually kills you,” Lauren said.

“That just gave me an idea,” Mia said, suddenly sounding less agitated. “They should put a warning label on this stuff. ‘Surgeon General’s Warning: This product makes you a bad mother.’”

One of the things I’ve noticed about the large-scale conversation about breastfeeding is that there is a shocking absence of humor, pathos, and humility on the part of most of those involved. It’s a shame, because we could probably get farther in discussions on the subject if we realized how ridiculous we all sound some of the time. Milkshake highlights some of the very real, very serious issues pertaining to the breast versus bottle debate, but in a way that feels more like a sitcom than a sociology class.

Weiss has chosen to e-publish her book, so right now it’s only available for download through Amazon and Barnes and Noble. For the sake of those of us without Kindles or Nooks (I know, I know, I’m a luddite… but I love the smell of a book. Sue me…), I hope some smart publisher will pick this up and make it a trade paperback. It’s far better than most of the mommy-centric chicklit out there, and while I worry that saying this will belittle the entertainment factor of the book, it is also an insightful take on the breast/bottle issue; one that urges moderation and understanding.

Read this book while you’re in the middle of nursing a cluster-feeding 6-week old; read it while you pump; read it while you formula feed. Just read it, because no matter how you’re feeding your baby, you’ll laugh at yourself. And god knows, we could all stand to do a little more of that.

Welcome to Fearless Formula Feeder Fridays, a weekly guest post feature that strives to build a supportive community of parents united through our common experiences, open minds, and frustration with the breast-vs-bottle bullying and bullcrap.

Please note, these stories are for the most part unedited, and do not necessarily represent the FFF’s opinions. They are also not political statements – this is an arena for people to share their thoughts, and I hope we can all give them the space to do so.

I relate on a visceral level to so many aspects of FFF Abbi’s journey, and I’m sure many of you will, too. Her story highlights how tough it can be adjusting to motherhood, and how breastfeeding difficulties can exacerbate an already emotional, difficult situation. There is no shame in admitting to yourself that motherhood is just one – albeit an intensely important one – facet of who you are as a person, and as a woman. It’s time we gave ourselves permission to see motherhood as part of who we are, rather than all of what we are.

***

The Day My Breasts Stole My Identity

The worst thing I heard during the first two weeks of my son’s life was “He only got half an ounce.” The second worst was, “Now your job is to feed your child.”

The first came from the sales clerk at a local retail establishment which claims to be a support network for breastfeeding women in my area and not a retail establishment, but my, do they know how to push the expensive nursing bras and clothing at you. She said this to me after I nursed my son in this establishment after weighing him, recording the pre- nursing weight, and then weighing him after feeding him. As a new mother of all of 10 days, I took this woman’s word as hardcore science, the word of God, and the authority on feeding. I took names for lactation consultants, bought the expensive bras, rented the pump, and cried the entire cab ride home with my son and mother. I thought it would be another few years before I screwed up my child, but apparently, I was starting early.

I emailed my friends who had babies that past year and asked for the name and number of their lactation consultant. I called the LC and she was available that afternoon, just 24 hours after my experience with the breastfeeding (non) retail establishment. She came over and sat down with me, my mother looking on, as she helped me get my son to latch, clucked her tongue and made sympathetic “mmhmmm” noises as I explained that he was born at 37 ½ weeks, not 40, and that he was a C-section, not a vaginal birth, and that I was still in a lot of pain and recovering from major abdominal surgery. She had an “aha” moment when I said he was born a little early and explained that while he was, as she put it, fully baked at 37 weeks, there are still little things that he may lack, like the ability to focus on my breast and the desire to breastfeed. I listened to her explain that I needed to feed him every two hours and that’s from when the first feeding starts and each feeding takes 40 minutes. After changing his diaper and burping him and getting him to stay awake long enough to eat, that leaves me with less than an hour to do things like sleep, shower, eat, check my email, function as the adult I once was. Then I said, “I feel like everything I am, everything I spent the past seven years working for has changed. I’m an educator, a chaplain, and almost a rabbi. Those are my jobs.” My LC looked at me and said those fateful words: “Now your job is to feed your child.”

The identity crisis that ensued in the next weeks was epic. My husband spent a lot of time mopping up after me as I cried at breakfast, dinner, and everywhere in between. I am in my last year of rabbinical school and will be ordained as a rabbi May 2012. I spent my year working as a chaplain, helping people who were dying while I was growing a new life. I am a teacher and write educational material that is highly regarded within my community. I spent a lot of time, effort, and money to get to this place. The idea of spending my summer “just being a mom” was one that had not yet hit me and I still had no idea how complex it would be. Just a few days before my son’s birth, I was working as a consultant on a national program. Now, my job was to feed my son.

This made me hate breastfeeding. The pain of breastfeeding, when my son would latch, was pretty bad, but nothing compared to the stories of bleeding and scarring that I heard from others. It was painful, but manageable with gel patches and warm compresses. My son and I would fight with each other to get him to latch onto my breast. He would arch his back and push his little hands against me and or put them into his mouth. I felt horrible as I held his head and tried to position him against my body. We couldn’t find a hold that both of us liked. Invariably, he would fall asleep. I was frustrated and he was frustrated and my husband stood by and watched all of it, feeling helpless. This was not bonding. This was not enjoyable.

Still, the pain was nothing compared to the feeling of having my professional identity stripped away and instead being seen as someone whose main purpose was to feed another person. I told my family, friends, and colleagues that I loved being a mother. I missed being a rabbi.

We took my son to the pediatrician when he was three weeks old. He was up past his birth weight, but still very small. The pediatrician asked if we wanted to continue to breastfeed exclusively or if we wanted to supplement with formula. Until that point, the only time my son had received formula was during the middle of the night feedings, so I could rest and let my body recover. When formula was offered as an option by the doctor, I jumped at it. Here was a medical professional telling us that we were not ruining our child by giving him formula. I went home and made my son a bottle and he happily ate it. I tried to nurse him later that day, but he just fell asleep. My husband looked at me getting frustrated and in pain and said that maybe it was better if I pumped. That was the last time I breastfed my son.

I pumped for another two weeks. I hated pumping even more than breastfeeding. I had low milk production and there was no way I was drinking any teas or taking herbs or supplements. If my body couldn’t do it on its own, something that a regulatory agency had not approved was not going to do it for me. I sat with the pump in the morning and the evening, scared to pump during the day because I was home alone with my son. If he needed me, what was I going to do while attached to the pump? Let him cry? Lose the milk? The rental pump was expensive, costing as much per week as a container of formula. By the end of my son’s fifth week, I was producing maybe four or five ounces of breast milk a day. When the rental was up, I had my husband return the pump and let my milk supply dry up. A few days later, my breasts were a normal size and didn’t hurt all the time. I was happier, my husband was happier, and my son was growing.

As I write this, my son is almost three months old. He smiles, coos, giggles, and has long and involved conversations with the animals that hang above him on his play mat. He follows me around the room with his eyes and loves to curl up and nap on his dad’s chest. He has a great relationship with both of his parents. I truly believe this is one of the many benefits bottle feeding has given our family. His pudgy legs and hands and full chipmunk cheeks are another.

A big benefit is that I am happier. I am not the only one who can feed my child, which gives me more freedom to be able to ease back in to my professional life. I can take a few hours a week and work on my sermons and education materials and not worry that I have to be home to nurse. I can enjoy my child and not see him as someone who is hurting me while I feed him. Formula was created for a reason and there are many children (including myself and my husband) who had it and are just fine.

I used to think of giving my son a bottle of formula as failing him because I could not even produce enough milk or having the patience to do what my Creator intended for me to do. As a religious and spiritual woman, I saw feeding my child as a holy act, made somehow less so because I could not provide it myself. However, I also believe in change and innovation within my religion, so why not in how I feed my child.

I got an interesting email from genuinely fearless lactation consultant Valerie this morning, posing the question: when helping new mothers who are attempting to breastfeed, where should the line be drawn between encouraging positivity and realistic practicality?

She writes:

Occasionally in the hospital setting I will run across a situation when maternal anatomy makes clear that breastfeeding will not be easily accomplished.(To a lesser degree, there are situations such as “late pre-term” babies, tongue tie, or just uncoordinated suckle on the part of the baby – all of which make the startup a bit more complex.)

I find myself struggling between wanting to give a realistic picture of what may be required to give breastfeeding a chance vs. sounding too discouraging.

The most recent situation encountered yesterday that inspires my question:A mom I was trying to help has the type of nipples that do not easily compress for a baby to latch onto.The best way for me to describe them is that they are “fibrous” or feel almost like scar tissue.Little to no flexibility and a wide diameter so not easy for a baby to learn to latch onto.She had attempted with her first child briefly.Interestingly, there was even a charted feed with this child post delivery.(I highly doubt this child was latched at all based on my assessment of her nipples!)The primary nurses rarely touch a mom’s breasts or nipples so seem largely unaware that this type of nipple is not going to be easy to latch onto or that they even exist!

This mom had come in intending to do “both” (bottle/breast).This can certainly complicate a one or two day old baby’s willingness to feed in the average situation – depending on ease of latch and volume of formula given.(I know that some people call it nipple confusion – I think the baby is not confused at all – – bring on the milk!) 🙂But her prior experience had her knowing that things were unlikely to be simply “latch and feed” so she knew what she would likely need.

Once the baby was awake and interested enough, it becomes easier to assess whether the baby was capable of latching – at least at this feed.In this case, as soon as I touched mom’s nipples (with permission granted 🙂 I saw that this would be no quick fix or a “just wait for the baby to wake up” fix.We tried a nipple shield for a few minutes without much success.I offered some suggestions to the mom about what options would be available in the short term – such as pumping – since the milk was coming – latch or no latch.With no milk removal, the supply would go.She affirmed that with her first child, she did experience engorgement.

I left the decision up to her as to whether she would like to begin pumping and / or continue to try on her own or with my help at successive feeds.(She had already given two bottle feeds since she’d been unable to latch baby on her own.)She had gone to the WIC breastfeeding class and seemed to want to try again with this child.I encouraged her to think about what she’d like to do if the baby continues to be unsuccessful in latching, and I would be happy to help her when she called.(Did not want to have her feel pressured at that moment – and wanted her to have time to think about it.)I don’t think she’d thought about pumping for bottles – even short-term – so I mentioned that some women do this for as long as they felt it was working for them.(Again – my personal opinion on this is to educate moms about how to do it, and acknowledge that it is often cumbersome and tiring – but possible for some moms who want to.)But even my suggesting this at this point made me wonder if I am indicating that I don’t think latch looks promising….

So – bottom line question.Do most moms want a realistic picture of what may complicate the breastfeeding success curve in the early days?Or that it may actually be impossible to latch a baby until the baby is possibly weeks old?As an LC, I certainly cannot predict what will happen, but sometimes it is obvious that success is not going to be quick or easy.I struggle between wondering if I should be realistic about what will likely happen without ending up being too discouraging in case the baby makes a liar out of me.

Besides making me wish I’d had a lactation consultant like Valerie in the hospital where I gave birth, this email made me think. If you had some physical condition which **might** make breastfeeding challenging, would you want to know beforehand?

Now, I think it’s pretty obvious where I stand on this; I believe forewarned is forearmed, and it is one of the reasons I write this blog, and encourage you all to share your stories every Friday. I’ve learned so much about lactation problems in the past 2 years, and as any regular reader of FFF can tell you, these issues are real, relatively plentiful and seldom talked about by medical professionals. In many cases, the problems aren’t insurmountable, but when a woman is a few hours postpartum or a newborn is losing precious ounces by the hour, it’s hard to find a calm resolution. Going in with knowledge of what you might be facing could help you be in the right state of mind, with the right folks on your team; you could do your research and not be at the mercy of whoever is on call from the LC team that morning (because god knows, it probably won’t be Valerie).

On the other hand, there’s that whole power-of-positive-thinking thing. Maybe ignorance really is bliss? If it’s a problem that may not even turn out to be a problem, could worrying about it do more harm than good?

Considering how many of us had physical impediments to lactation, I think we’re a perfect sounding board for any professional pondering these issues. So I’m asking you, FFFs – what do you think? If you were the woman in Valerie’s story, how would you prefer she handle the situation? Harsh realism, blind positivity, or something in between?

Conclusions The frequency of breast milk transmission of HIV-1 was 16.2% in this randomized clinical trial, and the majority of infections occurred early during breastfeeding. The use of breast milk substitutes prevented 44% of infant infections and was associated with significantly improved HIV-1–free survival.(http://jama.ama-assn.org/content/283/9/1167.short)

Detection of human immunodeficiency virus type 1 (HIV-1) in breast milk by culture and polymerase chain reaction does not necessarily mean that breastfeeding is a route of transmission, although evidence from several case-reports points in that direction. We undertook a systematic review of published studies meeting criteria that allowed determination of quantitative risk of transmission via breastfeeding. Based on four studies in which mothers acquired HIV-1 postnatally, the estimated risk of transmission is 29% (95% Cl 16-42%). Analysis of five studies showed that when the mother was infected prenatally, the additional risk of transmission through breastfeeding, over and above transmission in utero or during delivery, is 14% (95% Cl 7-22%). Where there are safe alternatives to breastfeeding, universal named testing of pregnant women would provide an opportunity to advise more infected women not to breastfeed and might thereby reduce the number of vertically infected children. Since breastfeeding protects against infant deaths from infectious diseases, breastfeeding is still recommended where infectious diseases are a common cause of death in childhood, despite the additional risk of HIV transmission. (http://www.sciencedirect.com/science/article/pii/014067369292115V)

“The question of whether or not to breastfeed is not a straightforward one,” says Professor Hoosen Coovadia from the Africa Centre. “We know that breastfeeding carries with it a risk of transmitting HIV infection from mother to child, but breastfeeding remains a key intervention to reduce mortality. In many areas of Africa where poverty is endemic, replacement feed such as formula milk or animal milk is expensive and cannot act as a complete substitute. The key is to find ways of making breastfeeding safe.”

In the developed world, the risk of transmission of HIV from mother to child has been dramatically reduced from about 25 per cent to less than 2 per cent thanks to the use of antiretroviral therapies, exclusive formula feeding regimes and excellent healthcare systems, but these are not available in resource-poor areas. (http://www.wellcome.ac.uk/News/Media-office/Press-releases/2007/WTX036809.htm)

More than 200,000 of the 500,000 new human immunodeficiency virus (HIV) infections that occur each year in children are the result of transmission of the virus through the mother’s breast milk

he availability of preliminary results of the study by Kuhn et al. in 2006 influenced the World Health Organization to change its recommendation that breast-feeding should preferably cease at 6 months to an alternative stance that “at 6 months, if replacement feeding is still not acceptable, feasible, affordable, sustainable and safe (AFASS), continuation of breastfeeding with additional complementary foods is recommended.”12 In contrast, recently published observational cohort studies among populations in Africa have provided compelling evidence that late postnatal transmission of HIV through breast-feeding can be substantial, increasing the risk of HIV infection by a factor of about 7.5.13,14 A recent nonrandomized, urban cohort study in Ivory Coast that offered short-course regimens of combinations of antiretroviral drugs to prevent mother-to-child transmission together with either exclusive formula-feeding or shortened breast-feeding found that both of these feeding options significantly reduced postnatal transmission of HIV at 18 months as compared with long-term breast-feeding, without increasing mortality.15AUTHORS connected with ABBOT, etc…(http://www.nejm.org/doi/full/10.1056/NEJMe0803991)

In the developed world, mothers with HIV avoid breastfeeding altogether and can instead feed their infants with formula. But in many low- and middle-income countries, formula feeding of infants is neither feasible nor safe. Sanitation is lacking, and clean water to mix formula is often not available. Many families cannot afford infant formula.It may be difficult to obtain enough fuel to boil the water to prepare formula safely. Formula-fed infants miss out on protective antibodies – passed on through breast milk – that ward off other deadly diseases. Formula feeding may also carry a social stigma in certain settings – the practice may be seen as a sign that a woman has HIV infection.